Factors associated with health CEO turnover - a scoping review

Background Chief Executive Officer’s (CEO) are integral leaders of health care organisation. Over the last two decades in United States (US) hospitals, it has been noted that CEO turnover rates are increasing, and it was reported that the CEO turnover rates have augmented from 14% in 2008 to 18% in 2017 in the private sector. In Australia, it was discovered that during two years, 41 executives had 18 distinct positions. It has been highlighted that the increasing CEO turnover is a major issue for Australian and international health care organisations. Some of the negative consequences of CEO turnover include organisational instability, high financial costs, loss of human capital and adverse effects on staff morale and patient care. Objective Our scoping review aimed to map and summarise the evidence associated with CEO turnovers in both health and non-health setting, and answer the following questions: 1. What are the reasons for CEO departure?, 2. What are the strategies to minimise CEO turnover? Results A protocol explaining the objectives, inclusion criteria and methods for this scoping review were specified in advance and published. This scoping review included 17 studies (13 health and 4 non-health setting) published over a 31-year period that investigated and described the increasing CEO turnover rates. All 17 studies identified causes of CEO turnover along with certain studies identifying facilitators of CEO retention. We classified CEO’s departure reasons into three major themes: organizational, performance, and personal. Organisational factors include CEO departures due to issues within the organisation, performance factors include issues with CEO’s work and personal factors captures personal reasons for CEO’s leaving their job. Conclusion CEOs are under immense pressure to deliver good results and drive growth while satisfying the interests of internal and external stakeholders. There are various reasons for CEO’s departure however the most common factor identified is organisational. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-024-11246-y.


Background
A Chief Executive Officer (CEO) is a top rank executive in an organisation who manages daily operations, makes corporate decisions and is the public face of the organisation [1].With changing economies, CEOs are finding their job to be increasingly difficult as they must manage tight budgets, model a positive work culture, manage daily operations and follow the Board's initiatives and strategic plans.The CEO role demands significant time, effort and critical thinking which makes the job one of the busiest roles within health care [2].CEOs deal with demanding scenarios like long, difficult work hours, separation from loved ones, severe mental health issues, and battling false online narratives and campaigns by social media [3].It was reported that almost a third (29%) of all the CEOs were forced out from their roles due to poor performance, a scandal or a strategic disagreement.Further, 7% of executives were formally dismissed and the remaining 66% quit with no reasons highlighted as such [4][5][6][7].
It has been highlighted that the increasing CEO turnover is a matter of concern for Australian and international health care organisations [8].Deleterious consequences of CEO turnover include organisational unsteadiness, budgetary issues, loss of human resources and adverse effects on staff wellbeing and patient care [5].Two thirds of health CEOs claimed that their decision to leave the organisation was solely their own [9].Majority of the CEOs perceive their departure as detrimental towards their organisation i.e., community relations, medical staff relations, hospital culture and employee morale get negatively impacted.Interestingly, it was found that CEO's turnover has a major knock-on effect on their executives.For example, the American College of Healthcare Executives (ACHE) report found that within one year of the CEO's departure, the chief medical officer and the chief operating officer also changed, 77% and 52% of the time [10].
Over the years, organisations have realised the importance of succession planning as it enables an organization to sustain itself in their leader's absence [1].Organizations need to take seriously how they develop leaders because a strong leadership team can make a big difference on how health can be advanced for everybody [11].In the health setting, it was noted that the average tenure of a CEO was about five years, and just over half (51%) had previously been a CEO at another facility [9].In Australia, long-term employment contracts are considered for non-health settings to ensure that CEOs have sufficient time and outlook for decision making.Information on contract length among Australian CEOs is hard to gather, because not all organizations uncover the contract in their yearly report [12].Among those Top 100 organizations that do uncover contract length stated that the contracts ranged between 3-and 5-years.Similarly, in the health setting, most CEO contract terms in USA are for three to four years and include provisions for renewal [13].
Two recent studies conducted in non-health settings have reported various reasons behind the turnover such as death, illness, dismissed for job performance, terminated for behavioural or policy-related problems, voluntary retirement, to pursue a new venture and departure following a merger or acquisition [13,14].However, in the health setting CEOs face different issues and challenges [5] hence may have various reasons to leave an organisation.The factors influencing CEO turnover in the healthcare sector differ significantly from those in non-health setting due to the industry's unique organizational structures and compensation models.Healthcare organizations, whether for-profit or not-for-profit, operate within a complex regulatory environment and face distinct financial pressures related to reimbursement and healthcare policies [15].Moreover, compensation structures for healthcare CEOs often include performance metrics related to quality of care and patient outcomes, which may not be as prominent in other industries [16].These differences in setting underscore the importance of considering industry-specific factors when interpreting results on CEO turnover in healthcare, as they reflect the intricacies of managing healthcare delivery amidst regulatory, financial, and mission-driven demands.To date, no scoping reviews were published to identify the evidence associated with CEOs turnover.Detailing this evidence will clarify the gaps in this area and enable further research therefore, this scoping review aims to examine the evidence associated with CEO turnovers in both the health and non-health setting.Barriers and facilitators for CEOs retention were also identified.These finding will immensely help the health care industry in retaining their CEOs leading to lesser disruption in health services resulting in quality patient care.

Method
The scoping review methodology followed the guidance published by Peters et al. 2020 [17].

Types of participants
Studies with CEO turnover in health and non-health settings are included.For the purpose of this study, CEOs were defined as the highest ranked officer within a registered corporate entity, such as a company or non-profit organisation.They usually report to a board of directors [18].

Concept
The factors or causes of CEO departure, barriers and facilitators contributing to CEO retention.

Context
The context of this review included both the health and non-health setting for comparative purposes.Examples of these included hospitals and corporate organisations.

Types of studies
Health care and non-health CEO turnover rates nationally and internationally were searched.Both quantitative and qualitative study designs were included in this scoping review.We also included systematic reviews to explore turnover and retention rates of CEOs by pearling of the reference list.Organisational reports through manual search, non-peer review literature was also included in the review.A protocol detailing the methodology for the current review was registered in Open science framework; Registration DOI-https://doi.org/10.17605/OSF.IO/8UXKH.

Search strategy
In consultation with a librarian, a three-step search strategy was utilised in this review.An initial limited search of Proquest (ABI/Inform), Medline (Ovid), CINAHL (Ebsco), Cochrane Library was undertaken which was followed by examining the text words contained in the title, abstract and of the index terms used to explain the article.Several studies were identified and deemed to be relevant to the review.A second search was conducted by identifying the keywords and index terms retrieved from our initial search was undertaken across all included databases.The below given databases were searched on 04 July 2021 using the support of a librarian: Proquest (select suitable relevant databases -e.g.ABI/Inform), Medline (Ovid), Pubmed, CINAHL (Ebsco), Cochrane Library, Informit databases, Scopus and Google Scholar.The above data bases were searched as they were anticipated to capture the relevant studies.In addition to the above, databases such as Web of Science, Business Source Ultimate and Emerald Insight were searched to identify the studies in non-health settings.All the above databases were explored during the final search.The search strategy of all the databases followed the same strategy mentioned in Appendix I.The reference lists of all identified reports and articles were searched for additional studies.We included literature in English in our review because of limited resources.Studies published from 1990 onward until 04 July 2021, were included as the CEO turnover issue has been identified since the changes in governmental funding mechanism for medical care [19].Funding system has evolved over the past three decades, which has imposed a significant impact on the way that hospitals and other health organisations are managed [20].The world economy and business models have experienced substantial transformation between 1990 and 2021, marked by the rise of globalization, the proliferation of digital technologies, and the emergence of new economic powers.These changes have reshaped industries, altered consumer behaviour, and necessitated adaptation to new market dynamics [20].The following keywords were used to identify health studies: CEO, Chief executive officer, Vice-president, Top executive, Turnover, Replacement, Retention, Churn, Succession, Cause, Factors, Succession policy/policies, Health care, Hospital/hospitals.Appendix 1 details the search strategy used for health studies.A similar search was used for non-health studies by adding key terms such as firms, company, business, industry, organisation, enterprise and corporation.

Exclusion criteria
Studies not identifying causes of CEO turnover were excluded.Publications in a language other than English were also excluded due to limited resources.

Data extraction
To address the review question, pertinent data were extracted from the included studies.To minimise the risk of bias and promote transparency, we registered and published the protocol before starting the review.Moreover, extraction was conducted by two authors to minimise the risk of errors and bias.When disagreement arose during data extraction conducted between authors, it was typically resolved through discussion, consultation with another senior researcher, or referral to established criteria, ensuring transparency and accuracy in the extraction process.The data extracted included the following: CEO turnover rates, causes, barriers, facilitators, authors, date of publication, country where study was originally conducted, aims/purpose, study population, methodology/ methods, context, details, and key findings and outcome measures that relate to the scoping review question.The extracted data were represented in a logical format and three step coding process was followed to extract high level themes from the literature where the data was categorised into personal, organisational and performance related factors behind a CEO's departure to enable a detailed map of the evidence [21].

Results
The database searches yielded a total of 138 citations (122 non-health and 16 health studies) after duplicates were removed and an additional two citations were found via hand searching (health studies).The titles and abstracts for these 140 citations were screened, with 86 papers excluded.The remaining 54 citations were considered for further detailed assessment of the full paper, and 37 were excluded due to having irrelevant aims (12 studies), study population (i.e., not relating to CEOs) (10 studies), not identifying cause behind CEO turnover (8 studies), and describing only facilitators of CEO turnover (7 studies).The search yielded a total of 17 citations for inclusion in this review i.e., 13 health and 4 non-health studies were included.A protocol detailing the methodology for the current review was followed.A flowchart showing the number of citations at each stage is detailed in Fig. 1: PRISMA flowchart of study selection and inclusion process.

Date & country where study was origihnally published
Table 1 illustrates studies that were published between 1990 and 2021.All the studies described in the review were undertaken in developed countries.Of the studies, Fig. 1 Prisma flowchart of study selection and inclusion process [22]  Abbreviation-American College of Healthcare Executives (ACHE), American Hospital Association (AHA)

Table 1 (continued)
94% were conducted in the USA, and 6% in Australia.There were no studies found in non-Western countries.

Aim/Purpose
Most of the health studies (69%) included in this review aimed to investigate causes for the increasing turnover of CEOs with two studies reporting on turnover in rural hospital in USA [25,26].Only one study was identified from Australia that reported on health care executive turnover including CEOs.Two studies measured the organisational impacts of CEO departure [5].Interestingly, a study explored the career trajectories of 4 CEOs i.e., what they are doing after leaving their CEO roles.

Study population
One of the studies which was conducted in Australia focused on health care executive's turnover in general.
The health care executives are CEO, Chief Nursing officers (CNO), chief finance officer (CFO) etc. [5].Other included studies focused specifically on CEO population.The population size for the included studies ranged from 4 to 2711 participants [26,29].

Study types
The types of studies ranged from Quantitative (23.53%),Qualitative research (11.76%) and report reviews (64.71%).Four of the health studies have used quantitative research to answer their research question [5,9,25,27].Two studies used a qualitative approach via conducting interviews [29,30] to explore CEO's perspective on roles, responsibilities and challenges of being a CEO therefore identified certain factors behind their turnover.The remaining studies reviewed the available data on CEO turnover from a hospital or health care college/ organizations.On the other hand, one of the non-health studies have also used a qualitative approach to investigate the turnover rates [30].The remaining three nonhealth studies reviewed the available data across various corporate organisations.

CEO turnover rates
In Australia, 16 executives left seven positions in 24 months [5] whereas the USA is experiencing similar issues and turnover rates is expediting with average CEO tenure of 3 years.Non-health industry reports similar trajectory of CEO tenure of 4 years [14,30,31].

Barriers
Health studies have identified certain factors behind turnover which ranged from lack of career advancement opportunities [4,5], lack of remuneration [9], pressure from board [13], lack of engagement of teams within the organisation [14], job being demanding and stressful [4], poor financial performance [14], low occupancy in hospital [23], lack of leadership support programs [28], inadequate salary and desire for better positions [27].
Non-health studies highlighted some causes for their turnover such as poor financial performance [14], pressure from broad [30] and high job demands [32].
Figure 2 details the classification of each of the studies.The studies ranged from having only one to all three of the components being organizational, performance and personal factors.The organisational component is aimed at focusing on organizational related causes due to which CEO leaves such as under-resourced hospitals, policy issues, merger and acquisitions.Performance components are aimed at the departure causes that are related to CEO's unsatisfactory performance such as being terminated by the Board.Personal factors focus on CEO's personal reasons behind resigning from their job such as family commitments, desiring a career change etc.
Sixteen studies have reported that CEOs depart due to organisational factors.Some of the reason's identified behind their departure were poor financial performance, under-resourced services, low bed occupancy etc. [9,14,23].CEOs have significant pressure in relation to finance and resource management, particularly if a hospital is under-resourced and has low bed occupancy rate which places more pressure on CEOs [8].
The second most common reason identified by the review behind their departure is due to their own personal reasons such as desiring for a career change, retirement, illness etc. [4,14,23,24].It is important to note that CEOs may desire for a career change or be willing to step down from their role for family commitments due to an increase in work demands [27,29].
Six of the studies shows that CEOs contracts get terminated by the board due to their poor performance in not being able to meet the target goals [14,[25][26][27]31].Some other reasons include lack of leadership, conflict with board members or medical staff, not aligning the goals with organisational vision, ethical misconduct etc. [14,26].

Facilitators
Health studies have identified that certain strategies may help minimise the turnover such as supporting CEOs by exposing them to leadership development programs to enhance team engagement [4,11].Exposure to leadership programs will help them to reflect upon their own leadership style and learn new skills and knowledge in terms of managing their organisation/team.Moreover, CEOs get some time to detach themselves from the busy environment to meet with other CEOs/leaders from other organisation and share experiences [4].The review suggests that developing good relationships with the board and its members may help in retaining a CEO as he/she may feel well supported [25][26][27][28][29]. Boards plays a vital role in supporting their CEOs as they are expected to intervene at the government level, where CEOs may not have the power or authority to do this [27].It is also imperative for the CEO to have a good relationship with board chair so that the CEO can discuss issues concerning their organisation and get support as they need [28,29].Other factors to minimise turnover were variety in the job, good pay, good fringe benefits and the opportunity for professional development.CEOs also appreciate variety in their role where they get the opportunity to act in another CEO related role.They also feel valued if their efforts or achievements have been recognised and acknowledged by receiving incentives or fringe benefits [27].

Discussion
The current scoping review consists of 13 health and 4 non-health related studies published over 31-year period that investigated and described the increasing CEO turnover rates.This review identified multiple factors associated with CEOs turnover in both health and non-health settings which is reported by the organisation.These included organisational, performance and personal.
A range of outcomes were measured in this review; they were the rate of turnover, causes behind turnover and consequences of turnover.Only one study identified the career trajectories of Ex-CEO's.Regardless of health or non-health background, most of the studies have suggested the need for having a succession plan in place within their organisation [4,5,9,[23][24][25].Researchers reports that an organisation performance suffers less from a CEO departure if they give other executive directors an opportunity to act in the CEO's role when they are on leave or seconded to manage another organisation.Therefore, sudden CEO's departure will be less impactful for the organisation as one of their own senior leaders will backfill the position until the recruitment process finishes, and a new CEO takes over [4].
The recruitment process in hospitals for CEOs varies, but many institutions are actively seeking capable and skilled leaders who possess a blend of healthcare expertise, strategic vision, and managerial acumen.However, challenges such as competitive market demands, complex regulatory environments, and the evolving landscape of healthcare delivery can impact the attractiveness of these positions to top-tier candidates [15,24].In Australia, long term contracts are considered for CEO's in nonhealth settings however the downside to these contracts is a large termination pay-out which could be salary for the entire remaining term of the contract.Nonetheless, a much bigger cost which is mostly overlooked is the implication for all other layers of management within the organisation [12].While long term contracts relieve the issue of CEO's short-term decision making, it limits the prospects of senior executives aspiring for a CEO role thus, they end up leaving the organisation [12].This review has identified similar trajectory of CEO turnover in both health and non-health settings which is due to similar reasons such as unsatisfactory CEO performance and personal factors such as death and illness.It has been noted that CEO's left mainly due to performance and personal factors within non-health setting when compared to organisational factors in the health setting.Apart from that, both settings have highlighted the importance of the board in CEO retention.Other factors such as investing in leadership programs and providing incentives to the CEO are some of the measures that may help in CEO retention.Moreover, having some realistic and clear key performance indicators (KPIs) will be a facilitator for CEO retention [14].One of the reasons why CEO's may fail to perform well in their role is that the board may not have set clear KPIs for them to achieve.Therefore, if not addressed, this may result in poor performance [31].Research shows that boards of directors play a significant role in CEO retention by implementing effective governance practices and strategic oversight, thereby influencing CEO turnover rates [35].By adopting measures such as succession planning, performance evaluations, and incentivizing long-term organizational goals, boards can mitigate CEO turnover and enhance stability within the executive leadership [36].Hospital CEO's come from a wide variety of backgrounds and college education.Generally, Licensing and certifications are not required however having clinical knowledge and commitment to the profession can be helpful in advancing toward becoming a hospital CEO [33,34].One of the retired hospital CEO stated that starting his career as a clinician has immensely helped in gaining the respect that he developed while working alongside other medical professionals which was critical to his success as CEO [33].
Further research is required to identify CEOs turnover and which interventions are likely to increase their retentions.Developing a retention model for this group of employees has the potential to enhance both recruitment and is likely to stabilise the turnover rates for this population.

Limitations of this review
The results described here are difficult to compare as both the health and non-health settings and structure of organisations are quite different.Additional limitation to the review was the language restriction as we only included studies published in the English Language as well as the how old some of the included studies were, spanning over a 31-year period.This review does not include an assessment of the quality of evidence, in keeping with a scoping review.

Conclusion
This review has identified multiple causes for the CEOs departure which has been classified under the following components as: Organisational factors, performance factors and personal factors.More studies are needed to explore the reasons behind CEO's departure so that retention strategies can be put in place to support CEOs at workplace.To minimize CEO turnover in hospitals, strategies includes fostering a supportive organizational culture that values transparency, employee development, and work-life balance, while also implementing robust succession planning programs to ensure smooth transitions and continuity in leadership.

Fig. 2
Fig. 2 Classification of included health and non-health studies based on causes

Table 1
Characteristics of included studies